When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
Apply a warm compress to the sacral area.
Wash the area with soap and water.
Reassess and turn the client in 30 minutes.
Massage the reddened area with lotion.
The Correct Answer is C
A. Applying a warm compress does not address the prevention of pressure ulcers and could potentially exacerbate skin issues. The primary focus should be on preventing further pressure.
B. Washing the area with soap and water does not effectively address the issue of pressure ulcer risk or the need for repositioning to alleviate pressure.
C. Reassessing and turning the client every 30 minutes helps prevent the development of pressure ulcers by relieving pressure on vulnerable areas, which is crucial for maintaining skin integrity.
D. Massaging the reddened area can cause further damage and is not recommended. Proper repositioning and pressure relief are the appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
To calculate the volume of hydromorphone to administer, we can use the following formula:
Volume (mL) = Dose (mg) / Concentration (mg/mL)
In this case:
- Dose = 3 mg
- Concentration = 4 mg/mL
Plugging in the values:
Volume (mL) = 3 mg / 4 mg/mL = 0.75 mL
Therefore, the nurse should administer 0.8 mL of hydromorphone to the client.
Correct Answer is A
Explanation
A. Paper masks and gowns used for isolation precautions should be placed in a designated biohazard bag before removal from the room. These items are considered contaminated and must be disposed of according to infection control protocols.
B. A sputum specimen should be placed in a sealed, labeled container before being transported to the lab, not in a biohazard bag for disposal.
C. The nurse's stethoscope should be disinfected but does not need to be disposed of unless it is single-use.
D. Bed linens are typically placed in a laundry bag specifically designated for contaminated linens, not in a biohazard bag.
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